Access for Sight-Impaired Consumers

Expression of Interest Form

Date:

Name (First & Last):

Email Address:

Street Adress (include suite # – if applicable):

City: Province: BC Postal Code:

Residence Phone No. (including area code):

Business Phone No. (including area code):

Mobile Phone No. (including area code):

Vision Status:
What, if any, adaptive technology do you use? Please be specific.

What, if any, social media channels do you use? Please be specific.

What, if any, mobile apps do you use? Please be specific.

If you use adaptive technology, please rate your level of proficiency with the following applications:

E-mail:

Word processing:

Spreadsheet:

Presentation software:

Share Point:

Twitter:

Facebook:

Other Social Media Channels:

Please describe why you are interested in joining the ASIC Board:

What special qualifications and/or skills would you bring to the position?

Please describe your past board experience (including the types of boards or committees on which you have participated):

Please describe your understanding of a board member’s role in organizations with which you have served:

What accommodations would you need to effectively participate and complete your tasks and/or responsibilities as a board member?

Please describe an occasion when you advocated for systemic change:

What are your other current volunteer commitments?

Can you contributea minimum of three to four hours per month to ASIC initiatives?

When are you most likely to be available to do volunteer work for ASIC?

Weekdays Weekends Evenings

Are you available to attend board meetings on weekday afternoons, usually in the 3:00 to 6:00 PM timeframe? NoYes

Which organization, if any, have you been nominated to represent on the ASIC Board?

If you will be representing an organization, how will you disseminate ASIC information to your organization’s executive and its members?

Have you read all the links about “Becoming a board member”, posted at ?

Additional Information:

______

Privacy Statement:.

The information collected on this form is used to assist ASIC in its Board recruitment process. If an individual becomes a board member, completed forms will be stored in secure individual Board member files.If an individual does not become a board member, the form will be destroyed. Questions regarding the collection, use and disclosure of this information is governed by British Columbia’s Freedom of Information & Privacy Protection Act.

Submission of this application is your consent to the collection, use, and disclosure in accordance with the purpose outlined above.

This completed form must be submitted to the attention of the Nominating Committee Chair within 21 days from the date of call for Expressions of Interest. You will be notified whether or not you have been selected for election prior to the Board’s annual general meeting. All candidates will be notified of the election results.